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#7301 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 I FL-STOCKTON CA 95202 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 37 E Hospital Road CITY/ZIP French Camp 95231 y <br /> v <br /> v <br /> CROSS STREET E1 Dorado APN 193-160-04 PARCEL SIZE -C'C LAND USE APPLICATION III Za <br /> OWNER NAME Subar Mani PHONE 983-0458 <br /> OWNER ADDRESS Same CITY/STATE/ZIP <br /> CONTRACTOR Delta Pump PHONE 466-9625 <br /> CONTRACTOR ADDRESS 646 S California Street - CITY/STATE/ZIP Stockton CA 95203 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE O C-57 TSI C-61 O D-09 ❑Other NUMBER 724778 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ISDomestic/Private ❑Irrigstion/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water system <br /> If diff—I from Owner: W,ter Sy,tem Name anncr Niure.,Phone Number <br /> TYPE OF WORK O New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> x of borings ❑Geotechnical x ofbonngs <br /> [I Monitoring Wells) #of wells ❑Soil Boring(s) <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump M Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool O Push Point ❑Other 'J <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter nl <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in T hickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bug/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> O Bentonite(201/6 solids) ❑Manufacturer Spec%solids % Name O Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other O Retardant/Accelerator(name) <br /> PLREUAL Installed By O Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick to ❑Christy Box O Stove Pipe <br /> PIMP XYSUbmersible ❑Turbine ❑Other HP 1 Pump Set 67 ft Standing Water Level 3O ft <br /> til <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NI INIMUNI 24 HOUR AD,'ANCE NOTICE:REQUIRED FOR INSPECTIONS <br /> SIGNED ��^ <br /> TITLE CEO DATE 10/12/06 <br /> N <br /> IC- <br /> e � <br /> O <br /> ,Se <br /> Ln o <br /> ! I <br /> 1 C�i <br /> H <br /> 6 <br /> NV <br /> D PRTI dEj <br /> S k 5 <br /> VI DEPARTMENT USE ONLY <br /> Application Accepted By �- Date / Area Employee ID# j 7 /.? <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By .-r=�. L c� � tip- Date t�2�zU ❑ WAIVER Received <br /> Constructed Well Depth / It <br /> COMMENTS (it // /'�) Sites / /.//11 / D i'n- ?�. / 1 ta'�.,-,�r� ,f <br /> 43,PE SC Received hec Amount Permit/ Invoice# Well ID# <br /> Codes Into ash Remitted Date Service R uest# <br /> Lf3 5 t <br /> EHD U-02-006 WELL PUMP PERMIT <br /> 1,127/2005 <br />